Episode 6-SANE (Dedicated to the Memory of Sade Robinson)

Transcript

0:00

This special episode of Pulse Check Wisconsin is dedicated to the memory of Sade Robinson with permission from the family and all other victims of domestic violence and domestic abuse throughout the city of Milwaukee and the state of Wisconsin. If you yourself are a victim of domestic violence, please do not hesitate to reach out for help. Help is available. You may call 1 800 799 7233 or text BEGIN to 88788. Take care of each other. Welcome to Pulse Check, Wisconsin. Good morning. What's up to all? How you doing? Good evening. Good afternoon. Whatever it may be to you. This is Chris Ford again, emergency medicine physician in Milwaukee. I want to thank you guys for joining us again for our now sixth episode of Pulse Check Wisconsin. Today is going to be a good episode. We're going to have some guests on with us to cover a Very pressing topic on the citizens here in Milwaukee, as well as throughout the state of Wisconsin. So, very excited to get into it. With that being said, let's start off with our first case. 65 year old male who arrives with complaints of chest pain. The patient states that his chest pain has been ongoing for the last three to five days. He's been on the road as a truck driver. He says that the chest pain began to worsen about a day ago as he was driving through Kentucky en route up through Canada, he started to have some chest pain that brought him to our emergency department here in Wisconsin. Patient has a history of diabetes as well as a history of hypertension or high blood pressure. He states that he has not been compliant as much as he should have been because it's been a while since he's been at home. He has some access but he had been rationing out some of his medications. He arrived with his blood pressure elevated. However, his heart rate and the rest of his vital signs are within normal limits. Patient has not been sick recently. He has no other complaints other than the chest pain, which appears to be getting worse, even as he's sitting still. As such, the patient was taken through our chest pain protocol. He had labs that were drawn. Chesa Cree was Performed as well, which was within normal limits. Patient had a test that was performed to determine if he had any signs of a blood clot that ultimately was negative. He has no history of blood clots either. The patient's EKG does not show any significant changes. And when I say changes, meaning no signs concerning for a heart attack that he would otherwise need to go emergently to the catheter lab at this time, Still, with his workup looking to be negative at this time, given his history as well as his pain and the rest of the story, he has what we consider to be an elevated heart score, which is a measurement that we use objectively to assess for risk of a heart attack. Because of this, the patient was admitted to what we had at the time, which was the observational unit. So this unit is on the side of our emergency department at the time. It did not have any inpatient beds, but it was more so a unit that patients could stay for less than 48 hours. Ideally, in order to complete their workup outside of the emergency department, the patient was initially reluctant to be admitted to this observational unit. However, as we implored the patient to stay, we were able to convince him that this could potentially be deadly, especially considering that he still needed to make a bit of a drive up through Canada, which was his final destination. Eventually he was able to tell us that he would stay, but he had someone else that was riding along with him in his truck still. As such, he requested that we send somebody out to his truck to tell this individual to come in to the emergency department. The person who was in the truck with the patient was a 19 year old female. We brought this individual to the room with the patient. The patient's stay in the unit from a medical perspective was uneventful. The patient had a stress test that essentially was performed to further rule out any signs of a heart attack. The stress test was positive and it was decided that the patient would eventually need to go to have a a cardiac stent in place. As we were arranging that, some of the very astute nurses were able to pick up that the Guest was not speaking very much to this patient. As such, some of the providers that were Taking care of the patient, made further inquiries into the relationship of this person who was riding on the truck with the patient. The truck driver was very passive in answering these questions. He would answer a lot of the questions for this patient. And so, we couldn't really get that much out in terms of the timeline where this individual met the patient as well as what the relationship was. At one point, the passenger of the truck decided to get up and go to the restroom. One of our nurses grabbed one of the social workers that was working in the department at the time and was able to pull this young lady aside and get more information. It was determined that the 19 year old was not a native English speaker and so a translator was.. utilized. After discussion with the translator as well as the social worker, ultimately it was discovered that this passenger was not there voluntarily. The passenger in fact was as it was later determined being trafficked and was not aware of where she was picked up initially. After this was discovered, police got involved. We contacted some of our forensic nursing staff and we're able to get this passenger in a safe situation. After the patient's procedure was completed, the authorities met with the patient and the patient was placed under arrest for human trafficking.

Chris : 7:25

So a lot to unpack in that case. First, I want to apologize for my voice. I'm currently getting over a cold at this time. Unfortunately, like every case this. case was encountered. In our emergency department. So it's a real life case. Of course for. Healthcare information protection as well as to Maintain anonymity of the patient. And the victim. We haven't provided any names or any specifics that would be identifiable to either. I think the biggest thing to hone in on, in this case outside of the actual medicine. Is that. As healthcare professionals and healthcare providers. A lot of times we are looking for things that are unspoken. We look for things that patients or the family members of patients are. communicating. without speaking formally. This is particularly. Useful in pediatrics where sometimes kids can't tell us if they are being abused or even if they're having a painful event, if they're really young and unable to really express their pain intensity or their pain quality. Also, this is very important in cases of domestic abuse. Domestic violence as well as in cases of trafficking. Like this, which unfortunately we see not infrequently in the emergency department. I think the biggest takeaway from this case. for the community. If you have a feeling that something. Could be going on such as domestic violence or such as trafficking. in someone else. You want to make sure that you allow that individual multiple avenues to communicate with you. A lot of times people are afraid. to discuss. some of the things that are happening to them. A lot of times there's a lot of shame associated with it. There's a lot of financial and social strains that are associated with domestic violence. And domestic abuse particularly. So if that individual is experiencing any of those things. It's really important. to be there for that individual and to offer assistance in any way that you can. And that can be in the form of providing some of the resources. That we provided at the beginning of this episode. Or helping them. Get in contact with local authorities. In order to remove them from that situation. If you yourself are a victim of domestic abuse or domestic violence. Definitely reach out to those resources that we provided at the beginning of the show. Because as we'll learn with our guests for the day. A lot of times it's too late when you are looking to ask for help. If you wait too long. Today we have two very special guests with us that are SANE Nurses S-A-N-E the acronym stands for sexual assault, nurse examiners. I wanted to give them a forum here to give very much needed information about what they do. And the effects that they have on the community, not only for the physical health of the community, but also for mental health. And so with us, we have Alison Lopez as well as Jackie Clary Robinson. Hope you enjoy the interview.

Alison: 10:58

my name is Allison Lopez. I am the project coordinator for the STARS program at the University of Wisconsin Milwaukee. And I am also a still practicing sexual assault nurse examiner in the Milwaukee area. I've been doing that for about 19 years. Um, so yeah. I'm very happy to be here. Awesome. Thank you so much. And I'm Jackie Clary Robinson. I am a, um, research assistant on the, uh, HRSA grants stars program and a doctoral student in her last year

Chris : 11:36

of congrats,

Jacqui: 11:38

um, and I still provide tele SANE, um, nursing within the state of New York.

Chris : 11:47

Thanks again, guys. So awesome to have you here. So I guess we can just jump into it. So I guess the first question is for Allison. In the intro, as I said before, we discussed a little bit about what SANE Nursing is, but I just want to delve a little bit more into the roles that SANE Nursing and some of the background of the program, just kind of what that, what that serves. Could you describe what a SANE is and some of the services that SANE provides?

Alison: 12:11

Yeah. So, um, a, a SANE is a sexual assault nurse examiner, which is a nurse or advanced practice nurse that has specialized training to provide comprehensive, holistic patient centered care to, um, patients that have experienced sexual violence. Um, additionally, you may hear the term forensic nurse examiner, um, as our scope is expanding a little bit in many areas where we are working with, um, patients, uh, that have experienced domestic and intimate partner violence, um, particularly patients that may have experienced strangulation, which we know is a risk factor for domestic violence homicides.

Chris : 13:00

Yeah, and that's a good point too. Uh, you know, in terms of strangulation, I know a lot of times, especially when we were working together in another life, you know, we had protocols around strangulation in particular. And as you said too, it can increase your risk for, for homicides and for, worse outcomes.

Alison: 13:19

Yes. So, um, in addition to having other health risks such as stroke and other complications later on in life, we know that women that have experienced strangulation within their relationship are 750 percent more likely to be a, victim of domestic violence homicide. So one of the focuses we try when working with patients and of course we want to make sure that we are providing patient centered care. We want our patients to have choice. One of the things that we, you know, also like to do is provide education around safety and what that can mean for a patient down the line. So really just meeting the patients where they are at and. providing options for safe care for the patients, but we really are our focus, which is also our focus in the training is to make sure that the care we are providing is patient led and patient centered. And that is truly the foundation of SANE or sexual assault nurse examiner care.

Chris : 14:29

Well, it seems, you know, it's doing a tremendous service in the community. I can speak as a healthcare professional myself. I always appreciate you guys coming there and especially at the most sensitive of times when you need, you know, someone with that training and with that sensitivity as well to kind of handle those sensitive situations. Jackie, is there additional training that is required of the SANE specialist? And if so, Is this a certification or is this a graduate nursing education? Are you sure you're getting your doctorate soon? So is it something along those lines or,

Jacqui: 15:01

So yes, there is. So the first thing I do want to say is that nurses led this effort early in the seventies and eighties. Tailored services in emergency departments and specifically in places like Memphis, Tennessee and in Minneapolis, Minnesota, Amarillo, Texas to really bring forth this subspecialty of forensic nursing. So the first we were also recognized by the American Nursing Association in 1995, as a subspecialty of nursing, the International Association of forensic nursing was then developed, and they created the first SANE certification. Currently there's about 1700 nurses that are saying certified through the International Association of Forensic Nursing. So they're one place to get some training and certification. And another professional organization that oversees forensic nursing is the American Academy of Forensic Nursing. And they have two certifications, one. Is the generalist forensic nurse, and then the advanced, um, forensic nurse for nurses that are APRNs, advanced practice nursing. So what we try to do in this training program is really look at all of the domains and competencies from both the International Association of Forensic Nursing and the American Association, American Academy of The Academy of Forensic Nursing and really encapsulate all of the training that is necessary. So including in our training is cultural safety and language, racism and implicit bias where nurses practice. So various environments of care, the scope and standards of forensic nursing, which was co authored by the American Nursing Association pillars of SANE practice, threads of SANE practice and practice consideration, care and sustainability of nursing of forensic nursing practice. So what we tried to do really more than anything else is focus our training on what is really essential for nurses to do when they're out in practice, which is the trauma informed, compassionate. Empowering of patients and ensuring that no matter where they practice, they could have this sort of autonomous and sacred relationship with their patients.

Chris : 17:21

Yeah, absolutely. And you know, I know in speaking from a first person perspective from being in a health care field, I know a lot of the nurses that I work with on day to day basis are SANE certified as well. And I know a lot of the younger nurses are going into it. Are you guys starting to see, you know, this, this, this boost in folks that want to go into it

Alison: 17:41

um, actually I think that we have been overwhelmed with the response to the training that we are so grateful to be able to offer. We actually have 86 applicants for our last training and had a You could only take a percentage of those nurses. So unfortunately we had, we did have to wait list some of those nurses, but yeah, the, the interest is definitely out there. I think it is just, you know, capacity wide. Capacity wise, just from, you know, our training and other trainings that there, there are just limitations that we have in our capacity to provide training.

Chris : 18:25

Well, it's a good problem to have, I guess, with a number of applicants, but yeah, we'll talk a little bit more about kind of next steps and some barriers or, you know, avenues that we can cross to improve, you know, some of that retention and increase our numbers. But I just wanted to get back to kind of. The Wisconsin standpoint is specifically the Milwaukee standpoint in terms of sexual assault and domestic violence. Where does Milwaukee stand in terms of that frequency of cases that we're seeing?

Alison: 18:53

Um, so I think that that is unfortunately a really hard question to answer because what we know is that sexual assault itself is underreported. And we know that it's estimated that 75 percent of victims that experience sexual assault do not report to law enforcement, nor many of those patients don't seek services at all. And so what we know about the national data is that approximately one in three women, potentially one in two women will experience sexual assault by the time that they are adults and or into adulthood. And one in five men will experience sexual assault. So we know what the data shows us. But we definitely know that we haven't had really the best ability to track that data. And you know, this is consistent with my practice as well. I think that What we can say about Milwaukee is that individuals of color are disproportionately impacted by sexual violence and particularly African American patients and American Indian patients and I can say that this is true. Also a true statement in regard to members of the LGBTQIA community, as well as patients or persons that have a disability. They are much more likely to be impacted by violence sexual violence. What we know about Milwaukee is that there has been an alarming increase in intimate partner and domestic violence, particularly impacting black women. And we know that some of the recent data has showed that up to 20 percent of homicides in Milwaukee are related to family, domestic or intimate partner violence. And there was also another recent study done in 2019 to 2020 that showed particularly in Wisconsin black women are 20 percent, 20 times more likely to be victims of homicide versus white women. So we know that There are populations that are unfortunately being really disproportionately impacted.

Chris : 21:12

Yeah. And that, you know, that kind of gets into the reason for this podcast was to open up the avenues and discuss some of these issues that we have within our communities, especially some of those social determinants of health. So, like you said, you know, you have populations that are already disproportionately affected by some of the most deadly, some of the most trying health care complications. And then you add on top of that, too, those SANE demographics, like you said, the American Indian demographic, the African American demographic, LGBTQ, you add that on top of it, and then you kind of get this, this, this amalgam of violence and, you know health care complications that can just be devastating for, for many communities and for generations on, because we're not even talking about some of the psychological trauma as of yet, Uh, that that will permeate in generations to come. Not only, you know, in the person who is affected by that violent, um, uh, event. So well, thank you for touching on that. So just in general, what are some of the services that SANE provides? So like, what are some of the services that are offered? And also is SANE a requirement if you seek care after an assault?

Alison: 22:20

So a sexual assault nurse examiner can assist with health concerns that are associated with experiencing a sexual assault. So again, our focus is to kind of meet the patient where they are at, make sure that they are informed about all of their options, but we really want them to be the, the driver of the care and to know that number one, they have options. Often we have patients. that and I'm going to kind of for the purpose of this podcast to talk just specifically about adults. I think, um, that because then that kind of goes down a whole nother path, but when we're talking about adult patients that to know that, I think that there are just so many things that victims don't know. you know, don't know about services that are offered. They're also often in a state of shock and disbelief. And they're, you know, sometimes there is a delay in when they are seeking services. So some of the things that we can focus on when, you know, per se, meeting them where they're at is, you know offering them options to care for their health such as offering prophylactic treatment for sexually transmitted infections such as chlamydia, gonorrhea, trichomonas also looking at their risk factors for HIV in relation to the assault. We can offer prophylactic treatment. Treatment for HIV to reduce the risk of HIV transmission. We can talk about if they are at risk for pregnancy, making sure that they understand that they have the option to be provided with emergency contraception and then also talk about any medical needs that they have. Do they, you know, need to see a physician for any medical reasons? And I think that You know, those are some of the health things that we can do. But when we, when we also meet with a patient, yes, there are things that we can do in regards to if a patient chooses to report to law enforcement. We can do things such as collect evidence. We are trained to obtain a history in a trauma informed way, again, focusing on reducing the likelihood that a patient is going to be re traumatized by maybe somebody who isn't skilled in working with sexual assault victims. We also so in addition to providing that option for evidence collection we can, you know, do a comprehensive examination, document injuries offer the option to take photographs. So again, Making sure that we really reinforce with the patient that these are all of the options that you have and and allow them to make the decisions that they think are best for them And one thing that I really would like to touch upon that there are a lot of people that don't know you know Walking into a hospital and even just saying that you are sexually assaulted is is very stressful. And you know, patients necessarily don't always know their, their options. And so I think to give them to bring some knowledge to the fact that a patient if they are within a specific time window has the right to have evidence collected and sent anonymously to the crime lab. And it can be held for 10 years until that patient makes that decision, whether they want to report or not. So I think a lot of times there are, you know, we know that patients often know the person that assaulted them. At least 90 percent of people know their offender. And so Coming to that decision, you know, immediately about making a police report, if they even want to make a police report, all of these different things are impacting their life. Um, you know, if they disclose this information and it's somebody that, you know, they work with or have a go to school with, or was it within their family, these are, You know, layers that are disrupting their life, right? And so, um, on so many levels. And so we want to be able to you know, provide these options and, and. reinforce that they don't have to make all of these decisions today. And we also want patients to know that if you come in and you seek sexual assault care and you decide that it's too much, you can always come back. You know, we want to support patients and meet them where they are at. The other thing that sexual assault nurse examiners can do is connect the patient with advocacy, which is so important to have. An advocate that can support their emotional needs. And if they choose to report to law enforcement, they have the right to have an advocate present for that police interview. SANEs can also assist patients with safety needs, discharge planning needs, any follow up medical needs that a patient might have. So we really want to focus on just the overall well being of the patient, but making sure that if patients are Wanting options such as evidence that these are options to them. And to answer your question that was a long answer that no, if, if a patient came in and said, I only want prophylactic treatment for sexually transmitted infection, do I have to have an examination? Again, we're going to meet that patient where they are at. Our, our goal is to provide care to them in what, in a way that is most meaningful to them.

Chris : 27:43

Yeah,

Alison: 27:43

at that moment

Chris : 27:44

at that moment. And that brings up a good point. And it highlights some of the thought process that goes into the SANE training as well as you know, some of that hands on approach with meeting the patient where they're at. A lot of times, patients, like you said, are not in the frame of mind. with everything that they've been through, right? A lot of times, you know, well, every time that this happens, this is something that has happened to that patient. And so allowing them that autonomy, allowing them the opportunity to say, this is not something else that we're going to do to you in terms of a treatment. You have the right to, to, to choose which way you want to go. If you're not in that timeframe right now, You know, like I said, we can, we can, we can hold on to, you know, whatever samples are collected, et cetera, uh, and, and broach that subject in the future, right? So I think that's, that's paramount and important to do, uh, in this line of work. With regards to, um, uh, SANE nursing services from my perspective as an ED provider, a lot of times what will happen is patients will come in and we'll, we'll have this, you know, unfortunate event occur. At that point in time, like I said, they're not in that mind frame. They're not in that space where they want to receive treatment or receive a SANE assessment is, are those services only available in the emergency department setting? Or is there any other avenues that are available to patients if they want to seek treatment at another time?

Jacqui: 29:10

So, um, one of the first grants that we partner with the U. S. Department of Justice was called a fast grant. What we had noticed is that specifically in indigenous communities, there was a severe lack of forensic nursing services. So we partnered with Lakota Ray up in Sawyer County. And Gerald Ignace in Milwaukee County to develop SANE programs there. And currently Gerald Ignace has a nurse practitioner who provides that care at Gerald Ignace and also provide, and there's three sexual assault nurse examiners at, at LCO. And our goal with this particular training is, is that we offer this all online so we could train nurses And then they get, get to be have accessibility to the program that then go back into their programs and we create clinical practice relationships with them to provide them the mentoring and the preceptorship after they've taken this care, after the, they've taken this training. So we're really excited about that because you're absolutely right. This is a problem. Survivors, excuse me, patients. Victims don't necessarily want to be in very busy emergency departments to access this their care. They want to have the autonomy to make decisions about where they go, and they want to have the decision making ability to choose what they want after a sexual assault, and we do know that many survivors of violence. Both intimate partner domestic violence and sexual violence and other forms of violence don't necessarily access care in emergency departments, they tend to be a little bit more busy a little bit more hectic, and this becomes a very sacred relationship between the nurse and their patient, and you can't do that in the emergency department, and It calls for an E. D. Nurse taking 456 hours out of their shift just to take care of that one patient. So our program is very focused on what we call advocacy driven care, which is working very much in the community at the community level with advocates to provide care wherever patients show up.

Chris : 31:27

Yeah, that's perfect. You know, like you're saying a lot of times, too, especially if the emergency department is busy, you know, Even if the nursing staff or the physicians or the nurse practitioners, uh, want to give that level of care, sometimes it's, it's not something that's feasible in that, in that moment. And so that again, just highlights the importance of programs like these. Um, I'll definitely link some of that to the website as well, Jackie, in addition to some of the articles that you sent out to, uh, that are, that are just, you know, fantastic and kind of illuminating what SANE nursing is, as well as some of the, um, uh, services available to patients. Jackie, I'll keep it with you. Outside of sexual assault, I've noticed recently, especially some of the hospitals that I work, there's an expanded role that's being taken on by SANE Nursing. I don't know if that's national, but I know especially in the city of Milwaukee, there are numerous, bullet points that we're, we're told to contact SANE Nursing to help us in these equally sensitive situations. Could you discuss some of those roles that are being expanded?

Jacqui: 32:28

Yes. Well, first I want to talk about what the type of nursing is. So we are forensic nurses. A subspecialty of what we do is taking care of survivors. Some sexual violence, but overall, and most forensic nurses work in hospitals, but also forensic nurses work within community anti violence programs, coroner's offices, medical examiner's offices, correctional institutions, and psychiatric hospitals. So, and we also answer the call to disasters and community services. I have a friend who works for health. The health and human services and she went down to collect forensic evidence on children that were separated from their parents. So we really answer a lot of call the full scope of forensic nursing practice. But I want to call out Milwaukee and the fact that in Milwaukee, where, you know, was only the second place I ever, I ever worked as a forensic nurse. We've been taking care of survivors of intimate partner domestic violence and strangulation since the beginning of our programs. So we always had that philosophical view of violence. Both from the perspective of someone who's experienced violence or somebody who has actually perpetrated violence or suspectedly perpetrated violence. So our role has always sort of been the umbrella, the, what I would say, the, the, the, the, the moment in which we provide medical care to anyone that's impacted by violence. Bringing sort of this. Overview of trauma informed care, this calm, collected autonomous practice, ensuring confidentiality. reality, creating sacred space, empowering patients for choice. We're there for every situation that involves violence. So, and again, I can call out Milwaukee County because it's not the SANE across the country. I've lived and worked in about 16 different states as a forensic nurse. So I have a sense of, of, of the gratitude that I have of the practice in Milwaukee County and the fact that Even though the statistics Alison mentioned the Lancet article and the horrifying fact that black women are 20 times as vulnerable to homicide in Milwaukee County. We as forensic nurses have been answering that call for a very long time and very proud of our practice there.

Chris : 35:07

Yeah, absolutely. So, so let's Let's take it a step back, Allison. If someone, let's say, was to be assaulted physically or sexually what, as a SANE nurse, would you say, from your professional background, what would you say would be the next steps that they should be taking after that assault or that that abuse?

Alison: 35:29

I think, um, what I would reinforce is that there are options out there for them and to be aware of what those options are. If they have medical needs, by all means, I would advise you know, seeking medical attention, whether that be in an emergency room or starting out with their healthcare provider, but to know that there are ways to if they don't want to necessarily seek that care right away that they can their confidential crisis lines that they can call to speak with a forensic nurse to hear options are all health systems, major health systems in Milwaukee do have forensic nursing programs now, which is amazing. And so if they want to seek forensic nursing care, they could present to any emergency department in the Milwaukee area and ask. to speak with a sexual assault nurse examiner or a forensic nurse if they have experience in intimate partner violence. But to know that there are ways to hear about those options prior to seeking those services. And, and I can also provide you with those crisis lines. A lot of times, you know, patients don't necessarily know what they want to do, what their options are. And I feel like knowledge is power to know that you have the ability to call an anonymous crisis line and say, this is what happened to me. The, you know, what helped me come to the next steps of what could be best for me. And so I think that if they are wanting to get that prophylactic for their health. By all means, I would, you know, recommend presenting where there are saying or said, or forensic nursing services available. Really, any, any emergency department in Milwaukee area could assist them and to know that there are trained practitioners that can We know that, you know, sexual assault survivors often have had negative prior experiences with health care. They are more likely to, you know, have a prior history of sexual assault more likely to have a negative interaction with law enforcement. So, to know that there are trained Practitioners that understand the dynamics that come along with sexual assault, and there is availability in the area if that's something that they want.

Chris : 37:55

Yeah. And, you know, like you said, a lot of times, anyone who's listening who has been to the emergency department for anything, you know, there's a lot of information coming at you, uh, and it's hard to remember what someone said at any point in care, in time of that care. Yeah. Let alone if there's been a traumatic injury or traumatic assault or a sexual assault like this, I couldn't even imagine being in the shoes of that individual trying to navigate, you know, everything that was said, all the options that were given. So you brought up a good point in that, you know, a lot of what the SANE Nurses are doing in that situation are providing that avenue and that autonomy. Uh, so that, you know, you're not, you're not expected to absorb everything at that SANE time when you're already kind of going through the process of processing everything that happens. So that's, that's excellent. Alison, I'll keep with you. You brought up something at the very beginning, um, about the demographics of folks that are affected by sexual abuse and by physical abuse. A common misconception behind abuse in general is that it is a gender specific issue and that's mostly experienced by those identifying as women. Um, could you speak to that a bit more?

Alison: 39:07

Yes. Um, again, definitely. Men are impacted by sexual violence. They are impacted by domestic and intimate partner violence. We we know again, one in five men will experience sexual violence in their lifetime. But again the likelihood that patients are men who have experienced this issue will seek services or report to law enforcement is even there's a greater chance that they will not seek services. And I think that there are many reasons for that stigma shame. They are more likely to feel unsupported, unbelieved by healthcare by law enforcement. We have a high percentage of patients that we see that are sexually assaulted in correctional facilities. Persons that are incarcerated are sexually assaulted at a much higher rate. So Yeah, that is definitely a huge misconception that there are many men that we see in the Milwaukee area that are sexually assaulted, and I can only imagine that there are so many more that we just don't even get to connect with because of all of the reasons that, you know, I mentioned, so. Which is very unfortunate because, you know, we know that patients that seek services for sexual assault care are less likely to have some of the health later on health, mental health concerns that develop after a sexual assault.

Chris : 40:41

Yeah. And like you said, a lot of that is societal, right? And so, you know, I can remember as a resident, you know, there's a guy who called because his wife assaulted him and, you know, kind of hear, to hear some of the unfortunate chuckling and things like that by some of the officers that were there with him. You know, it's something that is a barrier that we need to continue to break down, and it's something that, again, continues to permeate in populations that are most at risk, like you said, the locked facility or the incarcerated population, where, you know, this happens More than some folks would like to realize or like to admit to, but it is something that in that moment, you need that care. You need not only physical care, but that mental health care as well. Absolutely. So Jackie one thing that I was seeing in the news recently is that SANE programs have been getting some much needed traction especially within the state. Have there been any obstacles in furthering program retention and furthering program financing, things of that nature?

Jacqui: 41:42

So I would say the, the stakeholder buy in within institutions has really been a problem, you know, getting hospitals to recognize the subspecialty of forensic nursing and to hire them, compensate them fairly. And and, and commit to their lifelong training because everything in our subspecialty changes so rapidly that the hospital institutions and the community based programs need to invest in forensic nursing lifelong learning with CEUs, with attending conferences, with being, you know, being formed. And so Also, increasing our training to include health equity focused provision and really looking at the communities that are most and disproportionately impacted and focusing our care on their voices. their statements, letting them tell us what they need, how this care should be rendered, where it should be rendered. And we need to have more research to ensure that we are meeting their needs. And, and I know that we're falling short of that. We also know that some victims that are accessing care are getting bills from hospitals. across the country. And so there needs to be more research around that as well. There's been some recent research that's, that's discussed that and talked about patient outcomes related to that. Imagine a patient receiving a bill for a thousand dollars, 1, 500. I mean, you know, that could, that could cost a lot of trauma. for that individual patient. So, yeah, getting stakeholder buy in is really, really important. And, and also this collaborative, um, idea about us as a systems responding to violence, working really collaboratively together. So the advocacy and VOCA recipients within the state that are providing this amazing sexual assault, intimate partner, domestic violence advocacy care And forensic nursing and the criminal justice system really just working together to ensure that we are meeting the needs of the patient and whether they want us involved or whether they want just advocacy or just the criminal justice system, we have to be okay with whatever that patient decides that has to be the focus of our work moving forward and hospital systems have to be on board. And of course, federal government has to look at widening the VAWA. Language around what our work is, because in the VAWA language is specifically evidence collection. And that's not what we do. We provide trauma informed empowering, um, patient care, um, with our, with our patients. And that has to be crisis intervention. Everything that we offer is so essential. Essential to the thriving of our patients. So and VAWA needs to take a look at that and really create some more funding streams to ensure the sustainability of forensic nursing throughout the country.

Chris : 44:52

Yeah, and that was going to be my next question to one of the articles that you said was talking about some of the buckets of funding that is available for SANE nursing in the state of Wisconsin. Is it all through the hospital associations or, you know, the individual hospitals or is there some state and federal? granting or money available for, SANE nursing?

Alison: 45:12

So there are some programs that definitely support patients from the standpoint of a forensic examination. There is the crime victim compensation fund, which patients can utilize if they report the crime to law enforcement. There is also the sexual assault forensic exam fund which will it does not require a report to law enforcement for patients to access that service. But the the other aspect is, is while the, there are resources for the forensic care unfortunately often patients experience bills in the emergency department that might not be specifically associated to the forensic nursing care. So if they require x rays or other interventions that, you know, say they needed, you know, some advanced Radiology studies because they have experienced strangulation. Those are things that unfortunately can't be covered unless the patient reports to law enforcement and Fills out a crime victim compensation application. And we know that, you know, many patients are uninsured or underinsured. So if they don't have access to health coverage that could be another barrier why they don't seek care.

Chris : 46:31

Yeah, and to talk, you know, kind of insult to injury, right? Like a lot of times in a lot of these domestic violence situations, the person who is the victim of the trauma relies on the person who is the aggressor, you know, financially, that may be the source of their housing. And so, like you said, that may be another huge barrier if someone is expecting, you know, a large bill or anticipating that bill to come down the pike and they don't have a means to. to to to essentially financially float that.

Jacqui: 47:03

And within Wisconsin, it is crime victims compensation. That is the basis of the safe fund. The provision around safe is that they don't have to report to law enforcement, which is wonderful. And then I also sent you some of the 734 to Um, also, uh, create some reimbursement to hospitals for strangulation and domestic violence. But again, this is not going to be able to train every healthcare provider in the state of Wisconsin around trauma informed care, provide ongoing, SANE training or forensic nurse training throughout all of the nurses in Wisconsin, which is, you know, we hope to touch upon. Um, And, and then really be able to provide this care in these rural communities that, that you, that needed the most.

Chris : 47:57

And you bring up a good point too about rural populations as well. You know, I had the opportunity and the privilege to practice in some of the rural communities throughout the state of Wisconsin. And it is just as much of an issue, you know, outside of Milwaukee County as well. And to Allison's point and your point too, Jackie, you know, a lot of times patients won't present because it's even more of an intimate, um, uh, setting in the emergency department in the hospital. If you have a, you know, a 10 to 15 bed emergency department, you know, folks see continue walking in, folks will see you walking out, um, and it adds an additional layer of shame. Like you said, an additional layer of apprehension to seek those much needed. therapies and potentially get someone out of a bad situation before it turns worse.

Jacqui: 48:40

No, exactly. I was gonna say, you know, um, I started when I moved to Wisconsin when my husband and I moved there 20, uh, something years ago. I started in a very small community. And I would go into the grocery store and be like, Oh no, you know, and, and that, and that was me as the provider, not for the patient. So, yeah, the anonymity of working in this, uh, in a, in a big community is kind of me. Yeah, it's more difficult for people that are in rural communities because they know people at the hospital. They know the criminal justice system and the police. So it is really difficult. And these programs have got to be tailor made for them based on their feedback, what they need.

Chris : 49:26

Which is why that, like you said, the community buy in is important, right? You know, a huge part of I was able to. Participate in global health, uh, back before we had kids and had to worry about where they are. Uh, but, you know, at University of Wisconsin, and one of the big concepts that we, we, we were taught was that you have to have that community buy in, you have to have, you know, that village buy in because you, it's one thing to come in and, you know, dole out this North American or this, you know, industrialized view of medicine. Was a whole different thing to actually have the community have stakeholders there that can continue and further, uh, those efforts as per, you know, their. ideas of how that can improve their community itself. If you don't have that, then again, essentially you're just placing a bandaid, you're not helping the situation at all.

Jacqui: 50:13

I totally agree. And the beauty of me coming to a place like Wisconsin, especially in one of the more rural areas was the advocacy director said, I love this idea. I love what you're thinking about doing. Let's have a community meeting. Meeting. Let's host it at the hospital and let's see if we can get by in. And so we followed all of those recommendations made by the advocates, the advocacy coordinator and by the, the constituents in the community. And we tailor made that program just for them. And that's the way it needs to be done across the country. We need to listen to the voices of survivors. They will give us the information that we need.

Chris : 50:53

Absolutely. Well, Jackie, to kind of close it out here, if someone is interested in becoming a SANE nurse or implementing programs at their institutions and kind of similar a way that you were talking, how would they go about doing that? And how could they get in touch with you or any programs at the state?

Jacqui: 51:10

So, you know, the Wisconsin DOJ Department of Justice has an amazing SANE program live training that they provide three times a year and Allison jump in anytime you want here. We hoped to just supplement that with an online program for nurses that couldn't necessarily leave their homes if they have babies at home or if they're working full time, whatever their needs are. So we worked collaboratively, collaboratively with What's already out there. So nurses can access the UWM program, just like you did going on onto our site, leaving us a message and us getting back to them

Chris : 51:49

or contacting the

Jacqui: 51:51

Wisconsin DOJ. We also have the international association of forensic nursing who also has a program, but what I love about what this HRSA grant has offered us Is that we are now part of a I would say national program anywhere, anyway, where we are, where we get to talk to nurses from nurse educators from Duquesne from the University of New England down in Arkansas, and we're all trying to do the same thing. Train nurses, mentor nurses, get them out there working, get feedback from them about what worked or didn't work, get them back into our program so they can begin to train and create more and more momentum around what's essential to providing this amazing care. But also providing it wherever they are, you know, in in hospice care, in emergency care, wherever they are just creating this mindset around what essentially was nursing in the beginning, you know, before evidence based care, we were nurses that cared about the social justice of our patients, empowering them, meeting them where they're at. providing services where they're at. So you can contact us at UWM. You can contact the Wisconsin Department of Justice. You can contact the International Association of Forensic Nurses, the Academy of Forensic Nursing, but please reach out, come talk with us. We would love to share all the information that we have. And we

Alison: 53:29

can give you those links too, if you want, for nurses that might be interested.

Chris : 53:34

Absolutely. Absolutely. Well, Allison and Jackie, I thank you so much for coming out today and speaking with us. Um, again, we'll post all that information for anyone who is interested. I say, I want to say personally, from my perspective, thank you all so much for what you do in the community what you do throughout the state. I have a special place in my heart for all of my SANE nurse advocates that come into the emergency department and, you know, want to just echo how invaluable you are. Your services are for, for this patient demographic as well.

Alison: 54:05

Always good to see you, Dr. Ford, and I want to thank you for having us and, um, congratulations on all of the work that you're doing with Pulse Check Wisconsin. So

Jacqui: 54:14

it's amazing. Yes, It was a pleasure meeting you. And I've been listening to every episode.

Chris : 54:20

Awesome.

Jacqui: 54:23

Take care.

Chris : 54:24

Bye

Jacqui: 54:24

bye. Bye Dr.

54:25

Ford. So I want to thank our special guests, both Alison and Jacqueline for coming out and interviewing with us. I'm sure I speak for everyone listening. their information is invaluable. And I also want to thank them for all that they do in the community as well as for all they do to advocate for their patients throughout the city of Milwaukee. I want to thank you for listening. Again, please don't hesitate to reach out if you have any questions, if you have any show ideas. Thanks so much for your feedback thus far. I want to thank you for all that you've done thus far to help grow this podcast. Again, take care of yourselves, take care of each other, and if you need me, come and see me.